2014 - PCMH4A

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The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:

  • Behavioral health conditions
  • High cost/high utilization
  • Poorly controlled or complex conditions
  • Social determinants of health
  • Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver

According to NCQA, The intent of the element is that practices use defined criteria to identify true vulnerability—a single criterion, such as cost, may not be an appropriate indicator of need for care management.

The practice considers how its comprehensive health assessment (PCMH 3, Element C) supports establishing criteria and a systematic process for identifying patients for care management.

4.A.1 Behavioral health conditions.

The practice has specific criteria for identifying patients with behavioral conditions for whole-person care planning and management. Criteria are developed from a profile of patient assessments, and may include the following, or a combination of the following:

  • A diagnosis of a behavioral issue (e.g., visits, medication, treatment or other measures related to behavioral health).
  • Psychiatric hospitalizations (e.g., two or more in the past year).
  • Substance use treatment.
  • A positive screening result from a standardized behavioral health screener (including substance use).

PCC's recaller or EHR Patient List functionality can be used to identify patients based on billed diagnosis (recaller) or active problem list, lab result, or medication (EHR Patient Lists).

NCQA further explains how pediatric practices can go about identifying patients in need of care management:

Practices may identify children and adolescents with special health care needs, defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.” (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)

4.A.2 High cost/high utilization.

PCC has a custom srs report that will identify patients who had the most visits or charges within a time period. Use this report to identify patients in need of care management based on their high utilization of your services. Contact PCC support to get this report installed on your system.

NCQA provides other examples of ways to identify patients with high cost/high utilization:

  • ER visits.
  • Hospital readmissions.
  • Unusually high numbers of imaging or lab tests ordered.
  • Unusually high number of prescriptions.
  • High-cost medications.
  • Number of secondary specialist referrals.
  • Reports, alerts or other notifications from health plans indicating high cost or high utilization.

4.A.3 Poorly controlled or complex conditions.

To meet this factor, consider using PCC EHR Patient Lists to identify patients with high Blood Pressure, BMI, or particular lab test results.

4.A.4 Social determinants of health.

NCQA explains: Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include: availability of resources to meet daily needs; access to educational; economic and job opportunities; public safety, social support; social norms and attitudes; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation and others (Healthy People 2020).

4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.

NCQA explains: The practice has a process based on these criteria that is intended to allow for referrals by external entities and nominations by those closest to patients/families/caregivers.

4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR)

Assessment of a combination of factors 1–5 results in a subset of the practice’s entire panel of patients identified as likely to benefit from care management. Note: Patients identified in this element will be used to draw a sample for the medical record review required in PCMH 4, Elements B and C.

NCQA requires a numerator and denominator to be reported for this factor. Based on the care management criteria you have defined, identify how many patients you are considering in need of care management (numerator). The denominator is the number of total active patients at your practice which you can determine through the patient recaller report. Be sure to exclude patients with inactive, transferred, etc flags and include only patients seen at least once in the past three years.